It's Medical Monday! - Bentall or David? Two Ways to Replace the Aortic Root

If you've been told that you need surgery on your aortic root, you may hear two names come up during conversations with your surgical team: the Bentall procedure and the David procedure.

Both operations treat disease of the aortic root. Both replace the weakened portion of the aorta with a durable surgical graft. And both can be excellent operations in the right patient.

The biggest difference is what happens to your aortic valve.

A Bentall procedure replaces the aortic root AND the aortic valve.

A David procedure replaces the aortic root while preserving your own aortic valve.

So how does a surgeon decide which one is right for you?

Let's break it down.

First, What Is the Aortic Root?

The aortic root is the first section of the aorta, located immediately as blood leaves the heart.

It is an especially important part of the aorta because it contains the aortic valve and the openings of the coronary arteries, which supply blood to the heart muscle itself.

When the aortic root becomes enlarged, or aneurysmal, its wall can become vulnerable to serious complications such as aortic dissection or rupture.

An enlarged root can also stretch the aortic valve apart. When the valve can no longer close completely, blood may leak backward into the heart. This is called aortic regurgitation.

When surgery is needed, the surgeon has an important question to answer:

Does the aortic valve need to be replaced too, or can the patient's own valve be preserved?

That's where the Bentall and David procedures come in.

Option 1: The Bentall Procedure

The Bentall procedure replaces both the diseased aortic root and the patient's aortic valve.

The surgeon removes the enlarged portion of the aortic root and replaces it with a synthetic graft containing a replacement valve. The coronary arteries are then reattached to the new graft.

The replacement valve can generally be either:

• A mechanical valve

• A tissue, or bioprosthetic, valve

  
  

  

  
  

If a mechanical valve is used, it is extremely durable, but patients generally need lifelong anticoagulation with warfarin and regular INR monitoring.

A tissue valve usually avoids the need for lifelong warfarin, but tissue valves can deteriorate with time and may eventually require another procedure.

A Bentall procedure may be especially appropriate when the patient's original aortic valve is already significantly diseased, damaged, calcified, or otherwise unsuitable to preserve.

Option 2: The David Procedure

The David procedure, also called valve-sparing aortic root replacement or reimplantation, takes a different approach.

The diseased aortic root is removed and replaced with a synthetic graft, but instead of replacing the aortic valve, the surgeon carefully preserves the patient's own valve and reimplants it inside the new graft.

The coronary arteries are also reattached to the graft.

The result is essentially: New aortic root. Same aortic valve.

For the right patient, keeping the natural valve has some major advantages.

Most importantly, there is no artificial valve. That means a patient who otherwise has no reason to take anticoagulation generally does not need lifelong warfarin because of the David procedure.

It also avoids complications that can occur specifically because of artificial heart valves.

So Why Doesn't Everyone Get a David Procedure?

This is an important question.

Keeping your natural valve may sound automatically better than replacing it, but not every aortic valve is suitable to be saved.

Think of it this way:

If the aortic root is the main problem but the valve itself is healthy, replacing the root while preserving the valve may be possible.

But if both the root and the valve are significantly diseased, keeping that valve may not provide a durable repair.

Surgeons carefully evaluate the valve's leaflets, which are the thin pieces of tissue that open and close with every heartbeat.

They consider things such as:

• How healthy the valve leaflets are

• Whether there is significant calcium buildup

• Whether the valve is leaking

• Why the valve is leaking

• Whether the valve can be reliably repaired

• The patient's overall anatomy

• Whether the valve is bicuspid or tricuspid

• The patient's age and overall health

• The underlying cause of the aortic aneurysm

• The surgeon's experience with valve-sparing operations

  
  

Sometimes imaging before surgery gives the team a very good idea of which operation will be performed.

Other times, the surgeon may need to directly examine the valve during the operation before making the final decision about whether it can safely and reliably be preserved.

Bentall vs. David at a Glance

Bentall:

The aortic root: Replaced

The aortic valve: Replaced

Replacement valve: Mechanical or tissue

Blood thinners: Lifelong warfarin is generally required with a mechanical valve; it is usually not required after the initial postoperative period with a tissue valve.

Major advantage: Provides a durable solution when both the aortic root and valve need treatment.

Important consideration: The patient will live with an artificial valve and the considerations that come with whichever valve type is chosen.

David:

The aortic root: Replaced

The aortic valve: Preserved

Replacement valve: None; the patient's own valve remains.

Blood thinners: Lifelong warfarin is generally not needed.

Major advantage: Preserves the patient's natural valve and avoids many prosthetic-valve-related considerations.

Important consideration: The native valve must be suitable to preserve, and long-term valve function still needs to be monitored.

What If I Have Marfan Syndrome or Another Genetic Aortic Condition?

Valve-sparing root replacement can be particularly attractive for some younger patients with hereditary aortic disease because their aortic root may require surgery while their valve leaflets remain relatively healthy.

Patients with conditions such as Marfan syndrome are among those who may be considered for a David procedure when their valve anatomy is appropriate.

However, having a genetic condition does not automatically mean that a David procedure is the right operation.

The condition of the valve, the anatomy of the root, the patient's individual circumstances, and the experience of the surgical team all matter.

Does the Surgeon's Experience Matter?

Yes, especially for valve-sparing surgery.

A David procedure requires the surgeon to reconstruct the aortic root while carefully preserving the geometry and function of the patient's valve.

Because this operation is technically demanding, experience with valve-sparing aortic root surgery is an important part of the conversation.

If you're considering a David procedure, reasonable questions to ask include:

• How often do you perform valve-sparing root replacements?

• Do you think my valve can be preserved?

• How likely is it that you will need to replace my valve once you see it during surgery?

• What have your long-term results been with valve-sparing surgery?

• If my valve cannot be preserved, what type of valve would you recommend?

• Why do you recommend this operation for me specifically?

  
  

Patients facing complex aortic surgery may also choose to seek evaluation at a center with a team that regularly treats aortic disease.

There Isn't One "Better" Operation

It is tempting to think of the decision as: Bentall vs. David, which one is better?

But that's not really the right question.

A better question is: Which operation is most appropriate for my aorta, my valve, and my situation?

If your valve is healthy and can be preserved reliably, a David procedure may allow you to keep your natural valve for many years.

If your valve is significantly diseased or cannot be repaired reliably, replacing both the valve and root with a Bentall procedure may provide the more appropriate and durable solution.

And sometimes the final answer isn't known until the surgeon examines the valve during surgery.

The Bottom Line

Both the Bentall and David procedures can treat serious disease of the aortic root.

The difference is easy to remember:

Bentall = replace the root + replace the valve.

David = replace the root + save the valve.

But choosing between them is much more individualized.

Valve anatomy, age, underlying aortic disease, the condition of the valve leaflets, lifestyle considerations, and surgical expertise can all play a role.

If aortic root surgery is in your future, don't be afraid to ask your surgeon:

“Can my valve be saved? And if it can, is valve-sparing surgery the right option for me?”

Understanding why your surgical team recommends a particular approach can help you feel more informed and prepared as you make decisions about your aortic care.

Think Aorta!

- Zach